Interaction Form
Today's Date
(Required)
MM slash DD slash YYYY
Estimated time spent
(Required)
Please calculate in minutes
How did you hear about Digital Literacy?
(Required)
Choose one
Community flyer or sign
Computer help sign
Friend/Family
Librarian
Referral from agency/organization
Repeat customer
Volunteer initiated
Prefer not to say
Location
(Required)
Choose one
Arnett Branch Library
Central Library of Rochester & Monroe County
East Rochester Public Library
Gates Public Library
Glenmere Assisted Living
Hamlin Public Library
Irondequoit Public Library
Lincoln Branch Library
Literacy Rochester
Lyell Branch Library
Maplewood Community Library
Penfield Public Library
Phillis Wheatley Community Library
Seymour Library
St. Theodore's Parish
Sully Branch Library
Webster Public Library
Winton Branch Library
Computer Helper
(Required)
Person Completing the Form
(Required)
Choose one
Computer Help Volunteer
Customer/patron/student
Other
Other person or agency completing this form
Section 1: Customer Information
This information is to track the effectiveness of our work in the community and to demonstrate the need for our services. The personal information below is not viewable by outside individuals or agencies. We need age and ZIP code for these forms to help support the funding and continuation of the program. If you do not wish to share, please select the prefer not to say in those fields so that the volunteer may still record their work with you today. All the questions with drop-down answers have a "prefer not to say" option as well.
Name
First
Last
ZIP Code
(Required)
Age Group
(Required)
18-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
Prefer not to say
Gender
(Required)
Choose one
Male
Female
Non-binary
Prefer not to say
How would you best describe yourself? Select one or more.
(Required)
African American
African Native
Afro-Caribbean
American Indian/Alaska Native
Asian
Caucasian
Indian
Latino/Latina
Middle Eastern
Native Hawaiian/Pacific Islander
2 or more
Prefer not to say
Highest Education Level
(Required)
Choose one
Elementary
Some High School, diploma not received
High School/GED/TASC
Some college, degree not received
2-year college
4-year college
Advanced degree (PhD, MBA, MS, etc.)
Prefer not to say
Employment Status
(Required)
Choose one
Working/Employed
Self-Employed
Student
Retired
Unemployed, seeking work
Unemployed, NOT seeking work
Unable to work, Disability/illness
Prefer not to say
I am a(n)...
Adult Student
Immigrant (regardless of citizenship)
Refugee (regardless of citizenship)
Recently Incarcerated
US Military Veteran/Active Reserve/Guard
Section 2: What was Accomplished Today
Which areas were worked on?
Computer Literacy
Social Services
Applied for Services
Workforce Readiness
Northstar Digital Literacy
Civic Engagement
Financial Literacy
Health Literacy
Legal
Computer Literacy
Learn basic computer skills (typing, parts of a browser, etc.)
Create, navigate, or recover an email account
Create or navigate a social media account
Create, edit, or save a document or file
Learn new smartphone/tablet skill
Connect device to internet or Bluetooth
Complete an online search and/or navigate a website
Participate in online shopping/selling
Learn Microsoft Office/Google Workspace/LibreOffice
Zoom or other videoconferencing platform
Recover an online account (reset password)
Upload/download a file/document
Utilize print/fax/scan services
Digital photos (crop, edit, share, etc.)
Access library catalog or services
Device Management (Install, delete, updating software)
Create or organize files/folders on a device
Learn internet safety and/or online scam avoidance
Refer customer to 3-party for hardware issues
Refer customer to low-cost/discounted device provider
Refer customer to low-cost internet providers
Other (please specify)
Other computer skill (not listed)
Briefly describe
Social Services
Complete/submit benefit form(s)
Access online resources
Communicate with a government agency/representative
Other (please specify)
Other service (briefly describe)
Briefly describe
Applied for Services
Lifeline Program
Unemployment Insurance Benefits/ID.me (Digital Identity Verification)
Subsidized Housing
NYS of Health Marketplace
Supplemental Nutrition Assistance Program (SNAP)
Home Energy Assistance Program (HEAP)
Other (please specify)
Other service (briefly describe)
Briefly describe
Workforce Readiness
Create or update a resume
Applied for jobs/submitted resumes
Create employment correspondence
Read and understand work-related documents
Read and understand training/onboarding materials
Obtain information about college, trainings, or jobs
Apply online for education or training
Create job site account
Complete job skills assessment
Other (please specify)
Number of job applications submitted
Other workforce readiness (briefly describe)
Briefly describe
Northstar Digital Literacy
Basic Computer Skills
Internet Basics
Email
Windows 10
Windows 11
MacOS
Phone Keyboard Basics & Logging In
Microsoft Word
Microsoft Excel
Microsoft Powerpoint
Google Docs
Social Media
Information Literacy
Career Search Skills
Your Digital Footprint
Supporting K-12 Distance Learning
Accessing Telehealth Appointments
Civic engagement
Locate polling site
Research community-based organization (church, PTA, neighborhood watch, etc.)
Register to vote
Other (please specify)
Other civic engagement (briefly describe)
Briefly describe
Financial Literacy
Complete loan/credit application
Open or access a checking/savings account
Refer to tax/prep site and/or register for an appointment
Understand banking and/or credit process
Other (please specify)
Other financial literacy (briefly describe)
Briefly describe
Health Literacy
Navigate/create patient portals
Assist with Telehealth
Other (please specify)
Other health literacy (briefly describe)
Briefly describe
Legal
Access information on employment rights
Access information on housing rights
Complete a legal document
Refer to legal services when necessary
Other (please specify)
Other legal (briefly describe)
Briefly describe
Section 3: Overall Experience
Was the outcome(s) achieved?
Yes, the outcome(s) was achieved
Requires more time, customer will complete it independently
Requires more time, customer will return for more help
No, could not find a solution to achieve the outcome(s)
Received USB drive
No, not required
No, previously received a USB drive
Yes
Volunteer Comments
Customer Comments
Section 4: Sharing Your Success
We would like to highlight the work our program and our volunteers are doing to support the individuals in our community. Please consider sharing your success to help others see why we do what we do. You measure your own success; we are here to help you get there.
Would you be willing to share your story?
No, I do not wish to share my story publicly
Yes, I will complete the contact information below
Not at this time, but I am willing to be contacted in the future to share the outcome of my work with the volunteer
I have already submitted my store/contact information
Phone
Email
Please share some details about yourself and what your goals or successes are
E.g. job searches, employment opportunities, education goals achieved, learning a new language, finding better housing, applying to a program or service, community involvement
Username or Email Address
Password
Remember Me
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